But…
Everyone employs moral reasoning in various situations, almost daily. To pay taxes, to not speed, to honour promises – all require a sense of moral reasoning. Some things we know intrinsically as being good simple choices – to kill is bad – to give to charity is good.
But when it comes to making more complex moral decisions, such as enforced medication, declining leave or involuntary treatment – how trained are nurses in the process of moral reasoning?
In a recent rant, Mr Ian (that’s me) declared on the issue:
Currently I know of no guidance, training or ethical standards in psychiatry that provides this.
Were the processes of moral reasoning in ethical decision making discussed as a student in your course? I’m genuinely interested to know.
Kohlberg determined a process for assessing someone’s level of development in moral reasoning. He called it the “Heinz Dilemma“. There is a 27 min Radio 4 presentation on the dilemma which includes a brief mention on the application of moral reasoning to nursing in higher education (discussing Ethics within a Nursing Doctorate) right at the end.
This ‘dilemma’ requires the same process as employed in the case study vignettes. It may be reassuring to know then that, in this case (and many other ethical dilemmas), there can be no defined completely right answers – just preferred options that employ certain and appropriate principles.
I’ll paste it here and invite debate on the questions raised either above or below. There is no definitive right or wrong answer to the dilemma – and so the answers given are of no importance. What is important is the different ways of reasoning those decisions.
- A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman’s husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: “No, I discovered the drug and I’m going to make money from it.” So Heinz got desperate and broke into the man’s store to steal the drug for his wife.
Should Heinz have broken into the laboratory to steal the drug for his wife? Why or why not?
Isn’t ethics what you have when you don’t want to have to deal with the fact that people can come to very different decisions based on their own ideas of morality and moral reasoning?
But anyway, these kinds of succinct moral questions annoy me. There’s some obvious flaws in the statement of the question – the cost of raw-materials is not the entire cost of the finished product, for example, so the fact that the radium cost $200 does not mean that he was charging 10 times the cost of production. And there’s not enough information to make any kind of moral decision. Does Heinz have any other assets? Did he try to get a loan? How much has the druggist invested in the production of this drug? Is he offering it to other people at a lower price? Does the druggist have debts? Is he constrained to sell it at that price by his investors? Does Heinz’s wife want him to steal it or would it be completely against her own judgement? Do they have children who would have to deal with losing a father to jail as well as a mother to cancer? And these doctors, are they reliable? If the drug has only been recently discovered, how can the doctors know it cures this special kind of cancer? Maybe they’re part of a conspiracy with the druggist to defraud Heinz and his wife. Hey, if that’s the case, maybe his wife doesn’t really have cancer. Maybe she’s part of the conspiracy too?
Never mind there being no right or wrong answer, when complex situations are reduced to the amount of detail someone can pack into a single paragraph, there can’t be any answers at all.
Yes.
Because.
hmm…. so far – I’m not so convinced
1 Not sure – tell me everything.
1 Yes – because.
There is no definitive right or wrong answer to the dilemma
From a medico-ethical perspective this is a complex and multi-faceted problem with no easy answers. However, once all you intellectuals have been lined-up and shot by the dictatorship of the proletariate, the answer is obvious, and requires no exegesis.
So is that a Yes, because Socrates ?
Err… Umm… Ahh… dunno… Can I have my pills now? The evil pixies are telling write naughty words…
I don’t even think Mrs Heinz is ill (last time I saw her she seemed full of beans).
“I don’t even think Mrs Heinz is ill (last time I saw her she seemed full of beans).”
Jan, that’s priceless
Bugger the radium tablets, where would Heinz stand for stealing a packet of Rich Tea from the local shop because after all, a drink’s too wet without one!
errrrmmmmmm….well…..yes and no!
Yes and in humans can (and often do) develop to the point where they can make morally reasoned judgements
and no because I haven’t seen it so much in practise!
Well the responses were interesting. In particular there seems an absence from any nurses to commit to an opinion on right or wrong.
Nevertheless, the process of Kohlberg’s moral reason reasoning was not to bother with who said yes or no – but identify by what rationale they supported their answer.
He concluded from all the answers given in his studies that there were 6 levels of moral reasoning; each incrementing to include a wider perspective of the issues and inclusion of abstract concepts.
eg:
Yes he should steal it – cos he needs it for his wife to live. (life is important)
No he shouldn’t steal it – cos stealing is wrong. (rules are important)
..are both moral reasoning but at the same level – even tho the answers are different.
Other levels might include rationales such as:
No – because permitting breaches of law leads to mass anarchy, regardless of the individual consequences. (for the greater good)
Yes – because the law exists to preserve the rights of life – life does not exist for the purpose of having laws. If the law provides to allow another to deprive someone of the choice of life then it is wrong [This would be my decision and rationale].
The disappointment for me in this model of reasoning is that it states there is no right or wrong answer – just better ways of reasoning the answer you choose.
So – and what we really want to know is when it comes to making decisions; what’s the best way to decide the right answer? – who’s to know if those who utilise the greatest levels of moral reasoning are actually determining rightly or wrongly? All they are doing is implementing the most complex processes to come up with an answer.
So, answering morally debatable questions still does not come down to those who are more morally able to reason, as being able to make the ‘right’ choice – it means they are more likely to simply win the debate as they can present a wider stronger argument. Their answer will still depend on their personal influences.
You see this a lot on blog debates – arguments are usually ‘won’ by those who develop the most comprehensive argument – not necessarily the ‘right’ one.
Still doesn’t make it right tho – does it?
If anyone wants to use this argument at their next NMC professional ethics disciplinary hearing please feel free to do so – and good luck.
[What usually happens is the higher level 'reasoners' adopt a consensus view which may be by majority or by compromise of opposing views]
I’ve seen covert administration before (after an MDT meeting, or jam sandwich
), but never seen covert ‘sourcing’ before!With all new drugs we’ve intro’d there is always a massive cost to my budget. Is the druggist’s name Smithkline, Pfizer or Beecham by the way?
Iain
In response to some of the arguments. My government steals from me every month in respect of taxes. My local goverment steals form me every month in the form of local taxes. I pay in the form of national insurance, which has never reduced, for a pension which people older than me will recieve, that i never will, at a rate which has recently increased. I pay more for petrol. I pay more for food. I pay more for utilities. My costs continue to rise every month! (my internet rises next month too!).The druggist is very low down on my 3 year plan, but he’s waking up without some drugs in the morning! Took some paracetamol from him too as my head will be sore with eyestrain from typing!
Iain
@Mr Ian –
Sadly what happens in most arguments is that each side has already decided on its position based on very simple logic. Thought processes in brackets.
Person A: Puppies are nice (I like puppies)
Person B: Puppies are nasty. (I don’t like puppies)
A: Yes they are (I just like puppies is that not enough ?)
B: No they are not (I was once bitten by a puppy but am too embarrassed to own up to this )
A: They are furry and cute and make ideal companions for small children. (Hmm that was a bit weak)
B: They grow into dangerous ravening beasts that hump your leg and eat children and sometimes the other way around (good grief I can’t believe I just said that better come up with something better)
Now dafties would just stop here and start throwing cats at one another until someone gave up. Intelligent people start having to feel they have to rigorously justify what they feel to be the right position.
In nursing I have seen intelligent senior staff do frankly questionable things and then justify it to junior staff with long convoluted arguments. The junior staff (in some cases) not being an experienced arguer does not manage to come back with a similarly intelligent sounding answer and is deemed to have lost. Eventually this happens often enough and the new nurse (or student) gets mentally brutalised into the working culture and their dreams of effecting change and driving care forward are crushed yet again.
In the Heinz debate there is a right answer. There might be more than one right answer though. One of the things that make nursing such an interesting place to work.
Nurses (particularly mental health) often have to make quick decisions based on limited information. Do I detain, restrain or medicate etc. etc. Then have to document a thought process later that simply did not have the time to happen.
I did have a point but I lost it in my quest to refind this post.
@dazedandconfused –
In the Heinz debate there is a right answer. There might be more than one right answer though.
An interesting point. I’m not sure exactly how it works when those right answers are opposing in nature tho and no matter how you debate your point – there’s always someone who can bring an opposing answer of equal conviction.
In nursing I have seen intelligent senior staff do frankly questionable things and then justify it to junior staff with long convoluted arguments.
Indeed, it is theoretically plausible to argue for abusing patients – or at least ‘pushing their buttons’ – as this will prepare them to tolerate the real world. That sort of thing?
Nurses (particularly mental health) often have to make quick decisions based on limited information. Do I detain, restrain or medicate etc. etc. Then have to document a thought process later that simply did not have the time to happen
Absolutely. This is something that I’ve been through. My [last] dismissal was based on an ethical decision made within in a 15 second timeframe. My appeal included a 45 page “thought process” explanation (that was never actually called for in the original disciplinary) for which I was reinstated.
I think the issue in terms of the decision making – it’s not always just about making the right choice – remember how we were always told in school exams to ‘show your workings out – don’t just write an answer’? – well my ‘workings out’ were all technically correct even tho there was a split when it came to the “what would Jesus do?” answers.
What I wasn’t pleased with was being charged with the duty of being responsible for making the ethical decision – then some dilbert manager telling me they didn’t like my decision. But he no longer works there anymore – for some reason.
Does ideology trump facts? Studies say it often does
There’s a difference with facts in ethical decision making as facts direct answers – tho it does relate back to your point on “intelligent senior staff do frankly questionable things and then justify it to junior staff with long convoluted arguments” – usually made up “facts” are abundant.
A lot like politics.
[...] should be morally right or are there times when all four are be morally right. I think it was on Mental Nurse that the Heinz Dilemma raised it’s head – When are things [...]